Second Trimester Abortion

Three or four day outpatient procedure

Second trimester abortion (up to 26 weeks) patients also receive an ultrasound-screening exam at the very beginning of their appointment at Boulder Abortion Clinic. In this case, a more extensive examination is necessary. Among those features of the pregnancy evaluated at this time include the diagnosis of fetal age, which is made by measuring various parts of the fetus, such as head size and femur length, that give a precise knowledge of fetal age. Other evaluations include position of the placenta, the presence of, absence of, or unusual quantity of amniotic fluid, the presence of visible fetal anomalies, pathology such as fibroids in the uterine wall, and whether the fetus is alive or not.

Aside from variations in the content of educational and informed consent materials appropriate for the length of gestation, the second trimester patient experiences the same preoperative procedures as the first trimester patient. The main difference is that the second trimester patient experiences an extra day of laminaria dilation of the cervix.

The second trimester abortion patient returns on the second or third day (depending on her exact length of gestation) for replacement of the original laminaria with several new laminaria in order to continue and enhance the process of cervical dilation. This procedure, done under local anesthesia, usually takes only a few minutes, but it is an essential step in the process to assure maximum safety.

15 To 19 Weeks - Three Day Outpatient Procedure

From 15 through 19 menstrual weeks, the patient comes in at her appointed time for her abortion and is given a preoperative analgesic and sedative medication. In the operating room, the laminaria are removed and the cervix checked for adequate dilation. The amniotic sac is then ruptured with instruments under direct ultrasound vision. The purpose of this maneuver is to release all the amniotic fluid to the extent possible. This prevents the patient from experiencing an amniotic fluid embolism, in which the amniotic fluid can enter the bloodstream and cause death or serious complications. Because amniotic fluid embolism (AFE) is one of the most dangerous possible complications of pregnancy and abortion, Dr. Hern developed the technique of preventing this complication from happening.

After that, the uterine contents are evacuated surgically by using forceps and other instruments placed into the uterus through the vagina and cervix. An intravenous infusion (IV) is in place at this time so that the physician can give medication quickly for pain and to give medication that causes the uterus to contract as the abortion is completed

Late second trimester abortion patients receive all of their preoperative evaluation and consultation on the first day of their appointment, and return on the second day for the initial steps of the abortion procedure.

At 20 menstrual weeks and later, the first step in the abortion procedure on the second day of her appointment is an injection of medication into the fetus that will stop the fetal heart instantly. The patient is awake during this procedure, which is done under local anesthesia and with the use of direct ultrasound vision. The woman does not observe the fetus on the ultrasound screen in this process. The injection, done with strict attention to sterile technique, usually takes about ten minutes, although the appointment may take longer because of preparations that must be made.

Following the injection into the fetus, the first laminaria is placed in the cervix. The patient may leave at that time and must stay in Boulder unless arrangements are made for the patient to stay in a neighboring town.

On the third day, the late second trimester abortion patient returns for a brief appointment, at which time the first laminaria is removed and more are placed under local anesthesia. This process permits maximum gentle dilation of the cervix over a two-day period.

On the fourth day, the patient returns for her abortion. Following observation of vital signs (blood pressure, temperature, and pulse), the laminaria are removed and a long-acting local anesthesia is again placed in the cervix. Under direct ultrasound vision, the amniotic membrane is ruptured so as to permit free flow of the amniotic fluid from the uterus. The amniotic fluid is drained as completely as possible.

Dr. Hern developed this technique for the following reasons:

Removal of the amniotic fluid reduces if not eliminates the risk of amniotic fluid embolism (AFE), probably the most dangerous possible complication of late abortion.

Release of the amniotic fluid allows the uterus to contract and become firm, reducing the risk of perforation of the uterus with instruments.

Contraction of the uterus reduces blood loss.

Release of the amniotic fluid and contraction of the uterus enhances movement of the fetus and placenta into the cervix, the opening of the uterus, thereby adding safety and reducing discomfort of the procedure.

This maneuver permits the accurate measurement of blood loss, which is usually minimal. However, heavy bleeding may occur in late abortion, and it is absolutely necessary to know accurately the volume of this bleeding in order to guide fluid or blood replacement if this should become necessary.*

As with the earlier second trimester procedures (15-19 weeks), the later second trimester procedure (20-26 weeks) may require that the physician perform a surgical evacuation of the uterus ("dilation and evacuation" or "D & C") using instruments such as forceps to remove the fetus and placenta. All the other steps taken up to that point, such as use of laminaria, induced fetal demise, and medical induction, serve to enhance the safety of the late second trimester abortion procedure. The choice of procedures is dictated by the woman's safety needs at the time.

* Less than 1 in 2000 patients has needed a blood transfusion in second trimester and later abortions at Boulder Abortion Clinic.